Affordable Care Act

How to Challenge a Medical Claim Denial

Published on August 20, 2015


How to challenge a denied medical claim
When you see your doctor for treatment and have health insurance, you make a reasonable assumption that your treatment is going to be covered by your insurance company—at least to some extent. So when you learn that your insurance claim has been denied, you may be understandably frustrated.
Unfortunately, this is not an uncommon experience, but the good news is that there are some steps you can take to challenge your medical claim denial.

Step One: Call Your Insurance Company

Contact your insurer right away and ask them to clarify why the bill denied.
Medical bills are declined most often because the services rendered did not fall under the benefits provided by the plan. Sometimes, however, medical bills are declined by mistake or due to an error in the way the medical provider coded the services that were rendered.

Step Two: Work with Your Doctor’s Office

If it appears that the medical bill was coded incorrectly by the doctor’s office (coding errors are not uncommon), then go back to your doctor’s office and ask them to submit a corrected claim to your insurance company.

Step Three: Ask Your Insurance Agent for Help

If you don’t feel that your insurance company is assisting you in good faith and you want a second look at what your health insurance plan actually covers, contact your health insurance agent.
This is one reason why it’s always a good idea to shop for coverage through an agent like– an agent can serve as your advocate with the health insurance company in cases where it looks like the insurer made a mistake.

Step Four: File an Appeal

If the insurer persists in denying a claim which you believe should have been covered, file an appeal.
All insurance companies have an appeals process. If your doctor also believes the claim should have been covered, ask him or her to draft a letter in support of your appeal.
Once an appeal is filed, the claim will be reviewed (typically by a panel including doctors) and a decision is rendered. If your claim is still denied, a second appeal may be filed if you have new information to provide.

Step Five: Complain to the Authorities, if Necessary

If none of these avenues help, contact the office of your state’s insurance commissioner about the incident. You may also wish to contact the Better Business Bureau.

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